General Adult Psychiartry, Warneford Hospital, Oxford, UK.
Clin Med (Lond). 2014 Feb;14(1):42-3. doi: 10.7861/clinmedicine.14-1-42.
The need to ensure patient safety in the National Health Service (NHS) is a national priority. However, it has long been recognised that a culture of blame impedes learning from previous adverse incidents. It is important to feedback the outcomes of investigations into incidents to NHS staff, but junior doctors have little knowledge of learning points from investigations into adverse incidents. Learning from past mistakes would improve practice and the level of care provided by junior doctors. A forum for learning from mistakes could also provide an opportunity to review past incidents in an open and supportive environment. This could, in turn, start to change the current culture of blame in the NHS and contribute to higher standards of patient safety in the future.
确保国民保健制度(NHS)中的患者安全是国家的优先事项。然而,长期以来,人们一直认识到,责备文化阻碍了从以前的不良事件中吸取教训。向 NHS 工作人员反馈事件调查结果非常重要,但初级医生对调查不良事件的学习要点知之甚少。从过去的错误中吸取教训可以改进实践和初级医生提供的护理水平。从错误中学习的论坛也可以提供一个在开放和支持性环境中回顾过去事件的机会。这反过来又可以改变 NHS 目前的责备文化,并有助于未来提高患者安全标准。